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This document provides a proforma and guidelines for writing a case study report, including:
1. Selection of a patient and collecting their demographic and medical history.
2. Comparing the patient's condition to typical descriptions including anatomy, etiology, pathophysiology, signs/symptoms, diagnoses, investigations, and complications.
3. Detailing the patient's management including medical/surgical aims and treatments, medications, diet, and nursing care with assessments, diagnoses, care plans with rationales, implementation, and evaluations.
4. The report should conclude with a drug study, research evidence, summary, and bibliography.
This document provides a proforma and guidelines for writing a case study report, including:
1. Selection of a patient and collecting their demographic and medical history.
2. Comparing the patient's condition to typical descriptions including anatomy, etiology, pathophysiology, signs/symptoms, diagnoses, investigations, and complications.
3. Detailing the patient's management including medical/surgical aims and treatments, medications, diet, and nursing care with assessments, diagnoses, care plans with rationales, implementation, and evaluations.
4. The report should conclude with a drug study, research evidence, summary, and bibliography.
This document provides a proforma and guidelines for writing a case study report, including:
1. Selection of a patient and collecting their demographic and medical history.
2. Comparing the patient's condition to typical descriptions including anatomy, etiology, pathophysiology, signs/symptoms, diagnoses, investigations, and complications.
3. Detailing the patient's management including medical/surgical aims and treatments, medications, diet, and nursing care with assessments, diagnoses, care plans with rationales, implementation, and evaluations.
4. The report should conclude with a drug study, research evidence, summary, and bibliography.
01. Selection of patient. 02. Demographic data of the patient. 03. Medical history past and present illness. 04. Comparison of the patients disease with book picture. a) Anatomy and physiology. b) Etiology. c) Patho physiology. d) Signs and symptoms. e) Diagnosis - provisional & final f) Investigations g) Complications & prognosis. 05. Management:- Medical or Surgical a) Aims and objectives. b) Drugs and Medications. c) Diet. 06. Nursing Management (Nursing Process approach) a) Aims and objectives. b) Assessment and specific observations. c) Nursing diagnosis. d) Nursing care plan (Short term & long term with rationale.) e) Implementation of nursing care with priority. f) Health teaching. g) Day to day progress report & evaluation. h) Discharge planning. 07. Drug Study. 08. Research evidence. 09. Summary and conclusion. 10. Bibliography. M Sc NURSING: CLINICAL SPECIALITY I PROFORMA & GUIDELINE FOR CASE PRESENTATION I] Patient Biodata Name, Age, Sex, Religion, Marital status, Occupation, Source of health care, Date of admission, Provisional Diagnosis, Date of surgery if any. II] Presenting complaints Describe the complaints with which the child has been brought to the hospital III] Socio-economic status of the family: Monthly income, expenditure on health, food, education etc. IV] History of Illness (Medical & Surgical) i) History of present illness onset, symptoms, duration, precipitating/aggravating factors ii) History of past illness surgery, allergies, medications etc. iii) Family history Family tree, history of illness in the family members, risk factors, congenital problems, psychological problems etc. V] Diagnosis: (Provisional & confirmed). Description of disease: Includes the followings 1. Definition. 2. Related anatomy and physiology 2. Etiology & risk factors 3. Path physiology 5. Clinical features. VI] Physical Examination of Patient (Date & Time) Physical examination: with date and time. Clinical features present in the book Present in the patient VII] Investigations Date Investigation done Results Normal value Inferences VIII] Management - (Medical /Surgical) a) Aims of management b) Objectives of Nursing Care Plan IX] Treatment: S.No Drug (Pharmacological name) Dose Frequency/ Time Action Side effects & drug reaction Nurses responsibility Medical or Surgical Management. Nursing management X] Nursing Care Plan: Short Term & Long Term plan. Assessment Nursing Diagnosis Objective Plan of care Rationale Implementation Evaluation XI] Discharge planning: It should include health education and discharge planning given to the patient. XII] Prognosis of the patient: XIII] Summary of the case: IVX] References:
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